Loops
1000A
Loop repeat: 1
Submitter Name
- NM1*41
- PER
1000B
Loop repeat: 1
Receiver Name
- NM1*40
2000A
Loop repeat: >1
Billing Provider Detail
- HL*01 (Billing Provider Hierarchical Level)
- PRV (situational)
- CUR (situational)
2010AA
Loop repeat: 1
- NM1*85 (billing provider name)
- N3
- N4
- REF
- PER (situational)
2010AB
Loop repeat: 1
(situational)
Pay to address name
- NM1*87 (pay to provider name)
- N3
- N4
- REF
2010AC
Loop repeat: 1
(situational)
Pay to plan name
- NM1*PE (Payee)
- N3
- N4
- REF
- REF
2000B
Loop repeat: >1
Subscriber Detail
- HL*02 (Subscriber Hierarchical Level)
- SBR (Subscriber)
2010BA
Loop repeat: 1
Subscriber name
- NM1*IL (insured or subscriber)
- N3
- N4
- DMG
- REF
- REF
2010BB-1
Loop repeat: 1
Credit/Debit card account holder
(situational)
2010BB-2
Loop repeat: 1
Payer Name
- NM1*PR (Payer Name)
- N3
- N4
- REF
- REF
2010BD
Loop repeat: 1
Responsible Party Name
(situational)
- NM1*QD (Responsible Party)
- N3
- N4
2000C
Loop repeat: >1
Patient Hierarchical Level
(Situational)
If SBR*18 (self) then patient HL is not required
2010CA
Loop repeat: 1
Patient Name
- NM1*QC (patient name)
- N3
- N4
- DMG
- REF
- REF
- REF (situational)
2300
Loop repeat: 100
Claim Information
- CLM
- DTP*434 (Statement date)
- DTP*096 (Discharge hour) (Situational for inpatient)
- DTP*435 (Admission date) (Situational for inpatient)
- DTP*050 (Repricer Received date) (Situational for inpatient)
- CL1 (Institutional Claim Code)
- PWK (Claim supplemental information) (Situational)
- CN1 (contact information)
...
- HI / QTY / HCP (end of loop)
2305
Loop repeat: 6
Home healthcare plan information
(Situational)
2310A
Loop repeat: 1
Attending provider name
(Situational)
- NM1*71 (Attending physician)
- PRV
- REF
2310B
Loop repeat: 1
Operating physician name
(situational)
- NM1*72 (Operating Physician)
- REF
2310C-1
Loop repeat: 1
Other provider name
(situational)
- NM1*73 (Other physician)
- REF
2310C-2
Loop repeat: 1
Other operating physician name
(situational)
- NM1*ZZ (Mutual defined)
- REF
2310D
Loop repeat: 1
Rendering provider name
(situational)
- NM1*82 (Rendering provider)
- REF
2310E
Loop repeat: 1
Service facility location name
(situational)
- NM1*77 (Service location)
- N3
- N4
- REF
2310F
Loop repeat: 1
Referring provider name
(situational)
- NM1*DN (referring provider)
- REF
2320
Loop repeat: 10
Other subscriber information
(situational)
- SBR
- CAS (Claim level adjustments)
- ...
- OI / MIA / MOA
2330A
Loop repeat: 1
Other subscriber name
- NM1*IL (Insured or subscriber)
- N3
- N4
- REF
2330B
Loop repeat: 1
Other payer name
- NM1*PR (Payer)
- N3
- N4
- DTP*573 (Date claim payed)
- REF*4 (situational)
2330C-1
Loop repeat: 1
Other Payer patient information
(situational) (deprecated)
2330C-2
Loop repeat: 1
Other Payer attending provider
(situational)
- NM1*71 (Attending provider)
- REF
2330D
Other provider (refer above)
2330E
Other provider (refer above)
2330F
Other provider (refer above)
2330G
Other provider (refer above)
2330H
Other provider (refer above)
2330I
Other provider (refer above)
2400
Loop repeat: 999
Service Line Number
- LX (assigned number)
- SV2 (institutional service line)
(Situational segments)
- PWK
- DTP472 (service date)
- DTP866 (Examination date)
- REF6R (Provider control number)
- REF9B (Repriced line item referenced number)
- REF9D (...)
- AMTGT (Goods and service tax)
- AMTN8 (Misc taxes)
- NTETPO (3rd party org notes)
- HCP (Line pricing/repricing information)
2410
Loop repeat: 1
Drug Information
(situational)
- LIN (Drug ID)
- CTP (Drug qty)
- REF (Prescription or compound drug) (Situational)
2420A-1
Loop repeat: 1
Attending physican name
(situational)
2420A-2
Loop repeat: 1
Operating physician name
(situational)
2420B
Loop repeat: 1
Other operating physician name
(situational)
- NM1*ZZ (Mutual defined)
- REF
2420C
Loop repeat: 1
Rendering provider name
(situational)
2420D
Loop repeat: 1
Referring provider name
(situational)
2430
Loop repeat: 15
Line adjudication information
(situational)
- SVD (line ..)
- CAS (line adjustments)
- DTP*573 (date claim paid)
- AMT*EAF (amount owed)